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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj.,oe v.orz/ehd FACILITY NAME TANK ID # (s): FACILITY CONTACT NAME Cin l�il v la j v 3 0 �� 0 i MU'4— v� FACILITY ADDRESS SITE PHONE # WI AREA CODE /05 21/2"/v PKW 2bli ctS'2-- 2vt3 CITY CITY STATE ZIP CODE # OF TANKS AT SITE CONTRACTOR ICC # CA g5Z10 Closure Installation 6EDRetrofit APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME Cin l�il v la j v 2005 5 I 1 ✓L d -L. ()`Y� A -?— APPLICANT APPLICANT MAILING ADDRESS 2008 APPLICANT PHONE # WITH AREA CODE `//v h% lie Civ ,Le 3? - 3 8 ao S 3 (- s - / z -'.t (o CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) qI ,5 -z ci u Closure Installation 6EDRetrofit ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $345 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) $ PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) $ SAMPLING INSPECTION FEE = $ 115/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $345 / TANK # TANKS X $345 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $345 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID # (s) : PLAN CHECK FEE = $920 / FACILITY REPAIR PLAN CHECK DATE RECEIVED TANK ID # (s) : $ TRANSFER FEE _ $ 20 $ TANK RETROFIT REPAIR FEE = $345 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. $ PIPING REPAIR FEE = $345 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS DATE RECEIVED SR $ TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 115/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 115 / HOUR $ SAMPLING INSPECTION FEE = $ 115/ HOUR ALL FEES ARE BASED ON THE $115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST 11 FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 07/01109)